Well…I’m doing my internship. It’s going well. Except for the days I leave and want to call my mom. I want to hear her theories and crazy evaluations. I want to call Storm. I want her to tell me I shouldn’t be there. That I have a family to think of. That one of those folks is going to attack me and leave my kids without a mother. I want her to tell me I’ve wasted my education and all of my money because therapy is not a real thing and talking about things give them power…and I won’t argue with her. I will let her talk. I will listen to her and smile. That’s what you do with her when she turns into Negative Nancy…you listen and you smile.
And I realized today that I am about to be done. DONE. All of the years of school and three degrees. And my mom won’t be there to see it. A classmate was talking about graduation and I realized that I haven’t really even thought about it. I should go. I deserve to go. I’ve earned it…but I don’t want to walk if my mom isn’t there to see me. She is the reason I did all of this. To make her proud. To do what she wanted to do but never could. And to change my children’s world. Open doors. But mostly to make her proud.
Proud. And she would be. And she would tell everyone I had my PhD and got a job running a VERY important hospital and that I was going to make hundreds of thousands of dollars a year. She bragged like that. I will never know if she did it to let me know what she thought I was capable of or if she was really that delusional 😍 Either way…I miss it.
So I’m doing my internship…and then I’m done.
So…I have some social anxiety stuff. Jack has some social anxiety stuff. We don’t like talking to people and we don’t like people talking to us. And forget large crowds!!!! He started Kindergarten a few weeks ago and he had the ambitious goal of making a friend everyday. He got two friends and decided that was enough. But hey…he talked to other kids so I am proud!!
So I’m away at school and I decided that I need to change some things about myself. If Jack can do it…I can do it. I decided to make a friend a day. Yesterday I cheated a little. I re-engaged someone that was in a previous class with me. But I sought her out and made an effort to sit at her table during lunch.
Today was a little more difficult. I tried to work up the gumption to be social…but it just wasn’t firing. We split up into dyads and did role playing. My partner had “social anxiety”…Yes Kana, that’s your sign. So I made eye contact and talked with him after the exercise. He’s actually a little famous. I won’t disclose names but he has a shiny college bowl ring!!!
So tomorrow…I’m putting myself out on a limb and asking someone to be my study partner for the CPCE. The thought of being one on one with someone studying FREAKS ME OUT. But that’s what CBT is all about and I can’t ask clients to do something I wouldn’t do myself.
So, I’m working on a paper for school and something came to me that I feel the need to blog about. The 5th chapter of John tells the story of a man who can’t walk. He is sitting at a well in Bethesda where miracles happen…and he has been sitting there patiently for 38 years. Apparently he is waiting for someone to come and hand him the miracle of feeling. When Jesus asks him if he really wants to get well, the man tells Jesus that no one will help him get to the water. He also bitterly tells Jesus that when he tries to crawl to the well on his own…someone always steps in his way. The man was blaming his inability to get healing on outside forces instead of on his own self. Jesus tells him “Pick up your mat and walk”!!! At which point he does, and he is healed.
I wonder if that man laid there for 38 years afraid of what would happen if he ever DID make it to the water? He had gotten comfortable with where he was? Was he scared of feeling again, or was he scared that if he got there, he wouldn’t be healed? Did his fear of failure cause him to project blame on those around him? Either way, Jesus did not pamper the man. He simply told him to just do it – just get up and walk. The blaming and self-pity had been wasted energy. The time he had wasted on looking for reasons WHY he wasn’t healed could have been used getting himself to the water. Fear kept the man from being made whole. Jesus knew that, just like he knows our fears and doubts. He knows that we are human. He knows that we don’t like change.
I really don’t want to be the man waiting by the well for someone else to show me the way. I don’t want to be scared of change, something peculiar, something new. I’m ready to step out of my comfort zone and into something different. I don’t want to lay in wait for everyone else to move before I try to get what God has planned for me. I want to know what it feels like to move. That man wasted 38 years!!! I want to be able to say that I tried. I may get stepped on or I may drown in the water like a paralyzed fool, but I am not going to sit around and wonder what life could have been like if I wasn’t afraid to live…to feel.
There are almost 150 classes of drugs, all of which were primarily created to be used medicinally, “by changing the biological function of target cells through chemical actions (Doweiko, 2009, p. 18).” Pharmacology is the study of how these chemicals actions affect living organisms. It includes drug composition, interactions, therapeutic capabilities, and toxicology. Counselors in the addiction and rehabilitation field must have a working knowledge of all the components of pharmacology.
One of the most important parts of pharmacology is the route of administration for a drug compound, because this affects the intensity and speed of the drug’s action. According to Doweiko (2009), there are thirteen methods of administration, with primary routes including oral and injection. Oral administration has the longest effect time because it involves breakdown of the drug compound in the stomach and intestines before absorption into the blood stream. Because of this, some abusers prefer to crush pills meant for oral administration, and inhaling them intranasally. This method provides a faster effect time because it provides the drug direct access to the blood flow in the sinus cavity, but it is somewhat “erratic (Doweiko, 2009, p. 20).” Injection involves directly depositing the drug compound into a muscle, vein, or under the skin. One benefit of this method is an almost instant effect with no interference from the gastrointestinal tract (Doweiko, 2009).
The effective dose of a drug compound is the estimated amount of the drug needed to reach desired effects for a percentage of the population. The lethal dose is the estimated amount of the drug that would kill a percentage of the population. The therapeutic index measures the difference between the effective dose and a lethal dose. The lower the therapeutic index, the smaller the margin is between the compound being effective or becoming toxic.
According to Doweiko (2009), drug compounds “must enter the body in sufficient strength to achieve the desired effect (p. 21).” The prime effect of a drug compound is the therapeutic, or medical, benefit to a disease, illness, or condition (Doweiko, 2009). The secondary, or side effect, is the undesirable results of the drug compound. Peak effect indicates when the most powerful results of the drug compound are felt. The half-life of a drug compound is an approximation of the length of time it will remain active within the body. Generally, the faster the peak effect, the shorter the half-life of the drug (Doweiko, 2009).
The bioavailability of a drug compound describes how it is absorbed, distributed, broken down, and eliminated from the body. The process of moving the drug compound from the route of administration to the sight of action is absorption. The way the drug is moved throughout the body is distribution. Biotransformation is the detoxification, or breaking down the drug compound for elimination. Elimination is the process in which the human body purges itself of the drug compound (Doweiko, 2009).
When looking at the pharmacology of addiction, it is vital to look at all of the components of how a substance is introduced, processed, and eliminated from the human body. The faster a drug compound can be absorbed, allowing the user reach a high, the greater the risk of abuse and addiction by the user (Doweiko, 2009). Substance abuse counselors should be knowledgeable about the pharmacology of the drugs their clients abuse in order to understand the complex nature of addiction. They must know drug benefits, side effects, risks, and symptoms in order to be most effective.
Doweiko, H. (2009). Concepts of Chemical Dependency. (8th ed). Belmont, CA: Brooks/Cole Learning.
Models of addiction define theories behind why researchers believe a person becomes physically and/or emotionally dependent on substances. Even though it is a complex and often multi-layered battle, researchers have narrowed down the root causes of addiction (Cook, 2006). The three primary models presented by Doweiko in Concepts of Chemical Dependency (2009) are medical, psychosocial, and the disease of the human spirit.
The medical model views addiction as a disease or chronic illness, stating that people are biologically predisposed to become addicts (Doweiko, 2009). According to research, addicts have a lower number of dopamine receptors. Therefore, they are
biologically vulnerable to the effects of substances that cause the release of dopamine to flow properly to these receptors (Doweiko, 2009). Once exposed to the effects, these people have a more difficult time resisting abusing the substances (Cook, 2006). One risk of the medical model is that it creates an opportunity for addicts to avoid personal responsibility for their addiction
(Jenkins, 2011). It is still unknown whether generational abuse is a genetic pattern or a learned environmental behavior.
The psychosocial model suggests that addiction is a learned behavior of an addictive personality type (Doweiko, 2009). Theorists of this model do not believe addiction is a disease because the injured party contributes to and promotes the disorder, unlike other diseases (Dowieko, 2009). Instead, they propose that people who fall into a certain category of personalities become more vulnerable to social and environmental factors that lead to substance use and abuse (Cook, 2006). These factors cause the addictive personality to seek the relief of emotional pain through addiction. One downfall of the psychosocial model is that researchers are unable to agree on exactly what personality traits predict substance abuse and addiction (Doweiko, 2009).
The disease of the human spirit model suggests that lack of purpose and connection to a greater power lead to an unending void (Doweiko, 2009). According to this model, addicts have temporarily patched the void with the abuse of substances in order to escape reality. However, no amount of chemical use can permanently fill the spiritual and emotional void. God created humanity to be in relationship with him. Therefore, there is no outside substitute or fulfillment for the empty space that is created by living outside of a relationship with Him. People suffering from addiction become focused on the substance of their abuse. They lose sight of God. According to Doweiko (2009), “spiritual growth is impossible when people view chemical use as their first
When looking at the complex nature of the beast of addiction, it is important to take in account all of the factors involved and treat the person individually, and holistically. Counselors should look at the chemical, spiritual, biological, sociological, and psychological aspects in order to gain an accurate picture of each client. Therefore, it is my belief that it is vital to examine all three models of addiction to achieve the most effective treatment for therapy.
Cook, C. (2006). Alcohol, Addiction, and Christian Ethics. London: Cambridge University Press.
Doweiko, H. (2009). Concepts of Chemical Dependency. (8th ed). Belmont, CA: Brooks/Cole Learning.
Jenkins, D. (2011). Psy.D. Addiction and Recovery: Models of Addiction. (Video Presentation).
Abuse vs Addiction
SUBS505: Abuse and the Recovery Process
When discussing substance abuse, the terms “addiction” and “abuse” are often used interchangeably. Although substance abuse and substance addiction are both potentially hazardous, they are not the same. The difference between the two terms is subtle, but it is important to those seeking to understand the complex nature of substance dependency. Addiction is always caused by substance abuse. However, abuse does not always signify a substance addiction (Pinsky, 2003).
Substance abuse is the use of a substance for purposes other than it was intended to be used. Doweiko (2009) says that abuse is “using a drug with no legitimate medical need to do so, or in excess of accepted social standards (p.13).” In cases of abuse, there is not a physical dependence on the substance. The abuse may or may not have a negative impact on the personal life of the abuser, such as financial hardships and loss of relationships. However, many times the substance is either illegal, or is being used in an illegal manner (Pinsky, 2003). This may lead to legal struggles which open doors for financial, relational, or occupational problems.
Substance addiction begins when an individual has a physical or mental dependence on the substance they have been abusing (Pinsky, 2003). They begin to be preoccupied with the using and obtaining substance, neglecting obligations and ignoring social or personal problems caused by the use of the substance. Individuals who are suffering from addiction build up a tolerance and will go though withdrawal when they are denied use of the substance (Doweiko, 2009). These individuals will have financial, personal, and/or professional struggles due to the fact that they cannot stop the substance use in spite of the negative impact it has on their personal life. They may also suffer from legal issues stemming from their addiction (Pinsky, 2003).
When looking at the difference between the terms “abuse” and “addiction” there is a similarity, but also an obvious divergence. The impact of both on society is devastating. Doweiko (2009) says that the United States is responsible for over 60% of the worlds illicit drug use, and that alcoholism is the second most common clinical diagnosis. Substance abuse and addiction are becoming frequent topics of discussion in the media and the use of illegal substances has reached an all time high (Pinsky, 2009). Because of this, it is vital that professionals wishing to enter the field of rehabilitation counseling are properly trained and educated.
Doweiko, H. (2009). Concepts of Chemical Dependency. (8th ed). Belmont, CA:
Pinsky, D. (2003). Cracked:
Putting Broken Lives Together Again. New York: Regan Books.
There are many techniques used to treat and rehabilitate addiction, but the focus of this case is the use of Psychoanalysis on a fictional character who has presumably already received detoxification treatment for the use of Vicodin. Using Psychoanalysis in addiction therapy does present a challenge. However, several new research projects promote the use of many of the foundational treatments of Psychoanalysis. It is recommended that any type of addiction therapy be coupled with group therapy, as well as with a relapse prevention plan. However, this is certainly vital when using Psychoanalysis as a recovery therapy. The combination of these therapeutic processes allow for individual healing as well as group healing and cohesion. This paper concludes that all addiction therapists must be well rounded and integrative in their approaches in order to be successful.
Psychoanalysis Case Study of Gregory House M.D.
A Conceptualization and Treatment Plan
Drug addiction is a serious issue that affects a person’s emotional, relational, and physical health. One of the reasons that addiction is so difficult to battle is that substance use reinforces itself with the perceived positive effects. However, Khantzian (2006) says that too much emphasis is placed on the pleasure principle behind drug abuse. There are more important aspects to the underlying cause of addiction, which are mostly emotional and chemical in nature (Pinsky, 2008). Khantzian (2006) describes the difficulties in an addict’s coping skills, as well as trouble engaging their environment, as primary psychological reasons for drug abuse. For this reason, Psychoanalysis can be a useful tool in treating clients with drug addiction. The objective of this form of therapy is to discover familial or relational ties related to the drug use, and formulate a healthy support system conducive to recovery (Strean, 1984).
Dr. Gregory House is a 51-year-old Caucasian male who is currently seeking addiction counseling. His drug of choice is Vicodin. The client developed his addiction after a surgery and a misdiagnosed infarction left him with “chronic leg pain.” He currently walks using a cane, and claims that he does not necessarily have an “addiction” because Vicodin use does not interfere with his work. He also says that his habitual use of Vicodin is “not a drug problem, it’s a pain problem.” Dr. House has at this time, already completed in-patient rehabilitation and detoxification. He needs consistent follow up and addiction therapy, as well as a relapse-prevention plan.
Dr. House reports that he did not come from an affectionate home environment. He states that while he loves his mother, his father has an “insane moral compass ” and he avoids contact with him. House’s father was abusive towards him as a child, and several years ago, he discovered that John House is not even his biological father. However, he is not motivated to seek a relationship with his biological father.
In his daily life, Dr. House maintains purely superficial relationships. This has caused trouble for his most recent relationship with Dr. Lisa Cuddy. Dr. House realizes that his current behavior is unpredictable and irrational. He is seriously concerned about his own mental stability. He would like to investigate his narcissistic tendencies, because he feels that this may be the primary cause in the failure of his romantic, personal, and professional relationships.
Dr. House confirms that he did not have a nurturing or supportive home environment as a child. His father was a harsh disciplinarian and his mother was distant, which prevented him from building strong attachments with either of them. He was deprived from making community attachments because of his family’s military lifestyle and frequent relocations. He often found himself in foreign countries surrounded by children with whom he could not communicate. His only solace was in learning about other cultures through archaeology. Still, House does not (openly) report that he was lonely as a child. This seems to indicate that he has had an early emotional disconnect.
Because he has disconnected himself from his emotions, Dr. House struggles to build relationships with others. It is possible that Dr. House feels unworthy of valuable relationships, or more likely, that he cannot trust anyone outside of himself to meet his own needs. His failure to bond with others only serves to validate this feeling, and is probably rooted in his early parental model. Dr. House was deprived of an emotional attachment with either of his parental caregivers. The emotional disconnect is further demonstrated by his lack of motivation to connect with the man he now knows is his biological father. His difficulty building relationships with the two men in his life may be a sign, according to Psychoanalytical theory that he has not surpassed Freud’s Oedipal psychosexual stage of development (Freud, 1914/1957). Resolution of this stage would mean that Dr. House was able to identify with either John House, or his biological father.
Dr. House may have developed a negative self-view as a child because of his lack of intimate connection with others around him. Dr. House may also be afraid of the level of intimacy that is required from any non-superficial relationships, because his parents did not model intimacy for him. However, he masks these fears with strong narcissism and grandiosity. This defense mechanism allows him to deal with negative feelings. Dr. House has been unable to make connections with women, and usually resorts to paying for sex. Whenever he is close to developing a meaningful relationship, he self-destructs with narcissism, instead of exposing any vulnerability himself. This allows him to push people away and reinforces his internalized view that they are leaving because they are unworthy of his “greatness.” His relationship with Lisa Cuddy was his most intimate, primarily because after knowing him for ten years, she was able to see through his façade.
Dr. House seems to be conflicted between his cognitive self (which says he is lonely and wants a relationship with Dr. Cuddy) and his emotional self (which tells him that women cannot be trusted and he only needs himself). His lack of attachment is rooted in his detachment from his parents, and has weakened his capacity of forming autonomy. Dr. House seems to think that he is entirely self-sufficient. If he allows someone, especially a woman, to become so close that he is emotionally attached to them, he fears that he may lose something of this artificial self–sufficiency. This idea, and its proximity to the opposite sex, should be explored in relationship to Dr. House’s mother, according to Freud’s Phallic/Oedipal stage of psychosexual development (Jones & Butman, 1991).
Dr. House’s primary issue is his addiction recovery. Dr. Drew Pinsky (2008) says that addiction is less psychological than it is biological. However, the psychological factors must not be ignored, and are key to recovery . A recent study of addiction found that there is a great capacity for using Psychoanalysis in treating addictive behavior (Khantzian, 2006). Battling addiction can be a lonely struggle. Since Dr. House has been unsuccessful in building intimate relationships, he has been unable to build effective addiction treatment supports. Effective addiction recovery treats the nature of addiction, while nurturing the client’s ability to maintain will power (Pinsky, 2008). Having proper emotional and physical stimulation helps to keep the body alert and able to fight temptations. Support is a necessary part of temptation treatment, and can make or break rehabilitation (Pinksy, 2008). By developing intimate bonds with a support system, Dr. House will be allowing himself the safety of relationship building while revealing his vulnerability. This may be a gateway for him to develop more meaningful relationships.
In psychoanalytic theory, defense mechanisms are the supports to a weakened ego (Murdock, 2009) that defend against perceived attacks. Traditional Psychoanalysis usually confronts defense mechanisms (Corey, 2008). However, Pinsky (2008) thinks it is best to provide clients in recovery with healthy ways of coping before taking away the maladaptive ones. One way to do this is to re-frame coping skills and defense mechanisms and define healthy alternatives. For instance, Dr. House has gone without the use of drugs for his chronic leg pain for a year. He does not NEED medication for pain management. His drug use at this time is strictly mask nagging inferiority feelings and vulnerability since his break up with Dr. Lisa Cuddy. According to Dr. Pinsky’s (2008) theory, it would be advisable to teach Dr. House new ways of dealing with both his perceived leg pain and his feelings of abandonment (rooted in his early parental interactions) in order to effectively treat him.
Goals for Counseling
From a Psychoanalytic perspective, the goal of treatment for Dr. House is to help him gain insight into where his fear of vulnerability comes from, and how these experiences have negatively impacted his relationship building skills. It is important to bring to consciousness any unresolved issues that are causing current struggles in relationships. Dr. House is allowing himself to be isolated, which is hindering his recovery, on many levels. Forming strong relationships in a group rehabilitation therapy setting, along with a positive therapeutic bond with the counselor, will provide Dr. House a foundation for healthy relational skills.
It is also and important goal to help Dr. House search for underlying depression or anxiety caused by his lack of emotional connection. Addicts often are ill equipped to deal with strong emotions, leaving them pre-disposed to drug abuse, and at even greater risk for relapse (Pinsky, 2008). Defense mechanisms generated by Dr. House’s emotional detachment have, for the most part, been successful in his attempt at keeping his inner-self protected. However, when Dr. House began treatment for his chronic leg pain, he found a new way of coping. Freudian psychoanalytic theory associates addiction with the oral stage, the first need-gratifying stage of development (Murdock, 2009). Khantzian and Treece (1985) add that, “Opiates were said to produce a state reminiscent of a blissful closeness and union with the mother, which resulted in avoidance of separation anxieties aroused by the adolescent dependency crisis (p. 13).” Khantzian (2006) also believes that drug and alcohol abuse act as a defensive strategy that bridges the gap between a person’s functional and defective ego, allowing them to cope.
Dr. House provides an air that he is superior, even though he uses the advice of others in solving his diagnostic cases. This grandiose personality can be especially grating on therapists. It is important to confront Dr. House on these matters, without taking too much from his fragile ego. For instance, pointing out that he was assisted in solving a certain case, but commending him on a job well done. One point that would be important in using confrontation with Dr. House is to not be affected by his narcissism and allowing it to cause counter transference, and feelings of negativity towards him. I would search my reasons behind any confrontations before hand and have an understanding of how it will benefit Dr. House.
Establishing the relationship
Considering the fragile state of Dr. House’s internalized ego, it is important that I reach out to him with acceptance and empathy. Narcissism prohibits individuals from achieving satisfaction in relationships, work, or other activities (Khantzian, 2006). He needs to see that relationships can be nurturing, even if, and especially if, an individual is broken. For this reason, Dr. House also needs to be able to forge relationships with others in his peer group and therapy group.
Khantzian (2006) says that people who struggle with their need to be acknowledged, to love and be loved, will be at risk for substance dependence. Dr. House’s drug use provides him with a synthetic validation for his narcissism. Since he began treatment and detoxification, he no longer has that artificial crutch. It is important on my part to be favorable and feed into his strengths to provide him with sincere encouragement during the initial sessions. The effects of this will hopefully be a building of mutual trust and respect. Dr. House needs to learn comfort in confiding, and the effects of being accepted, even when his attitudes are unacceptable.
Analysis of transference
One of the most important factors in the therapeutic process is the client/therapist relationship. Without it, transference cannot be assessed. In fact, Strean (1994) says that all patients “will respond to interventions in terms of the transference (p. 110)” and that the therapy model, setting, or experience of the counselor, make no difference in recovery. Because of the vital role transference plays in the healing process, I recommend that Dr. House connect with his feelings about me during our sessions, and openly confront and express them. We can then begin to match these emotions with other instances of similar feelings and their root cause.
In the Psychoanalytical therapeutic model, insight provides a look into the emotional and logical though process. The goal of insight is to find how Dr. House’s insecurities were formed and provide him with an opportunity to correctively deal with these experiences. Self-realization of past conflicts and perceptions of feelings that have been repressed will allow Dr. House to form other options for reactions, and develop other behavior patterns (Khantzian, 2006).
However, insight alone is not enough. It is vital that Dr. House makes a connection between insight and an emotional experience. Substances themselves are such strong behavior reinforcements, that patients need a strong emotional counteract-ant. This will hopefully ensure the client can counter the strong compulsion for them. Dr. House likes to solve problems. This makes him feel adequate, and feeds his need for validation. I would like to challenge him to see himself as a puzzle, and ask him to seek himself for insight on his situation.
With time and support, it is hoped that Dr. House will find meaningful relationships to be satisfying. The goal of this form of therapy is to allow Dr. House to recognize his own fear of inadequacy and how his grandiosity is interfering in his daily relationships. Dr. House needs to be validated for his strengths, but learn that weakness is acceptable, and can even be an asset. Dr. House’s self-esteem need not be threatened by his vulnerabilities. This paper concludes that addiction therapists must be well rounded and integrative in their approaches in order to be successful. Dr. Pinsky (2008) says that while addiction is “treatable” it is not “curable.” It is important that Dr. House heal his relationship patterns if he wants to treat his addiction.
Corey, G. (2008). Theory and practice of counseling and psychotherapy. Belmont, CA: Thomson Brooks/Cole.
Freud, S. (1914/1957). On narcissism: An introduction. In J. Strachey (Ed. and Trans.). The standard edition of the complete psychological works of Sigmund Freud. London: Hogarth Press.
Jones, S. L., & Butman, R. E. (1991). Modern psychotherapies: A comprehensive Christianappraisal. Downers Grove, IL: InterVarsity Press.
Khantzian, E. (2006). An ego/self theory of substance abuse. National institute of drug abuse: Theories on drug abuse: selected contemporary perspectives. 30.
Khantzian, E., and Treece, C. (1985). DSM-III diagnosis of narcotic addicts: Recent findings. Archives of General Psychiatry. 42, 11-26.
Lipowski, Z. (1984). What does the word psychosomatic really mean? A historical and semantic inquiry. Psychosomatic Medicine. 46, (2) 153-171.
Murdock, N.L. (2009). Theories of counseling and psychotherapy: A case approach. Upper Saddle River, NJ: Prentice Hall.
Pinsky, D. (2008). Cracked: Putting broken lives back together again: A doctor’s story. New York, NY: HarperCollins Publishers.
Strean, H. (1994). Essentials of psychotherapy. New York, NY: BrunnedMazel Publishers.